Student Support Services (SSS) is a federally funded TRIO grant program of $390,421 for 2024-2025 through Title IV (TRIO) of the U.S. Department of Education. SSS provides academic and personal support services to eligible students in an effort to assist them to successfully complete their education and achieve their personal and career goals. SSS offers a wide variety of services and activities designed to meet the individual needs of each student. All services are FREE to those who qualify. Any P&HCC student may apply to participate in SSS. Information obtained from this form is used only by SSS and kept strictly confidential. It does not in any way affect your admission to P&HCC or your eligibility to participate in other services and activities offered by the college.

Application to participate in:

ROAD (Reaching Out & Achieving the Dream) Scholar Program of

Student Support Services

Thank you for your interest in our Student Support Services program! Please complete this application as thoroughly as possible. Fields marked with an asterisk (*) are required. You cannot save and restart this application. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. If you have any questions, please call our office at (276) 656-0296.

General Information:

Last Name: *

First Name: *

Middle Name

Date of Birth: *

Social Security Number:

Residency

Gender

Marital Status *

Address: *

City: *

State: *

Zip Code: *

Home Phone Number:

Cell Phone Number:

P&HCC Email Address:

P&HCC Student ID:

Family Information:

Father's Educational Level: *

Mother's Education Level *

How many people in your household at home?

Family Income Range:

Most Recent IRS 1040

Your Academic Information:

Educational Background

How many classes are you taking?

Current GPA:

How's your academic standing?

Ethnicity/Race

Race, Hispanic

Race, American Indian or Alaskan Native

Race, Hawaiian or other Native to Pacific Island

Race, Asian

Race, Black or African American

Race, White

Disability

Do you have any type of disability? (ex. physical, medical, psychological, learning, attention deficit) *

Were you ever in a special education program while in school? *

Personal Inventory

I want to make changes in my life.

People expect too much of me.

I’m well-liked by people my own age.

Work often upsets me.

I have too many things going on in my life.

My feelings are very important to my family.

At home I lose my temper easily.

I’m very often in a good mood.

I can easily make decisions.

I feel I always have a need to improve myself.

I find it very hard to express my opinions in front of other people.

I’m easy to be with.

I find it hard to get used to new things.

I’d rather give in than fight.

It’s not easy being me sometimes.

My family puts pressure on me.

I’ve often thought of leaving home.

Other people are better looking than I am.

I’d like to feel better about myself.

My family is very supportive of me.

Needs Analysis

List your Goal(s) at P&HCC

List your Academic/Personal Strengths (things that will help you as a student)

List your Academic/Personal Weaknesses (things that you want to work on as a student)

I would like assistance with the following: (check all that apply)

1. Career Information

2. Curriculum/Major

3. Advising

4. Tutoring

5. Computer Training

6. Study Skills

Reading Textbooks

Notetaking

Test Taking

Organization/Time Management

Learning Styles

Stress Management

Other

7. Transfer Assistance

advising

college information

campus visits

8. Services for a Disability

9. Adjusting to College

10. Family/Spouse Support

11. Peer Support

12. Other

Sign and Submit:

Applicant Signature *

Please select a signature verification type.

I certify that the above information is true and correct to the best of my knowledge. In addition, everything mentioned in this application packet—(all forms) are verified by this signature. I hereby authorize Student Support Services to obtain all academic and financial information necessary to determine my eligibility (to obtain any financial documents from the financial aid office, regarding parents and myself, that assist with documenting eligibility with SSS), as well as reporting requirements for the Department of Education, to include but not limited to: total financial aid award & unmet need.

OFFICE USE ONLY:

Eligibility requirements met: First Generation / Income / Disability

Student Accepted o Yes o No Date:______________ Staff Initials__________

Reason Accepted_______________________________________________________

APR #_____________________